Aims and Objectives: To determine the relationship between depression, perceived and received social support.Materials and methods: Forty elderly (age >60 yrs) subjects were assessed for depression and social support using Berlin Social Support Scale.Result: Significant negative correlation was seen between perceived social support and depression (r = −.413; P < 0.01). There was no significant correlation between depression and received social support.Conclusion: Perception of social support in elderly is affected by depression. Adequate treatment of depression which improves negative cognition would help in the perception of social support for elderly subjects who are depressed and aid in recovery.

Keywords: Depression, elderly, perceived social support, received social support

The elderly population is now becoming of considerable concern around the world. The proportion of people age 60 and over is growing faster than any other group. Compared to 1970 population estimates, by 2025, the projected elderly population is expected to increase to 223%. Between the years 2000 and 2050, the world wide proportion of persons over 65 years of age is expected to more than double from the current 6.9% to 16.4%. [1] As health care facilities improve in countries, the proportion of the elderly in the population and the life expectancy after birth increase accordingly. This is the trend which has been seen in both developed and developing countries. [2] About 60% of the 580 million older people in the world live in developing countries and by 2020 this proportion is likely to increase to 70% of the total older population. [3] The elderly population in India has possibly grown from 7.5% to 8.2% in the last decade or so. According to official population projections, the number of elderly persons in India will rise to approximately 140 million by 2021. The gender ratio among elderly was about 972: 1000 in 2001, in favour of females. Another feature is a relatively higher ratio of females to males in the elderly population than in the general population for all the years since independence. For males the rise was more modest from 5.5% to 7.1%, while for females there had been a steep rise from 5.8% to 7.8% during the five decadal Censuses from1961 to 2001. It can also be observed that the percentage (of elderly) had all along been higher in rural areas than in urban and usually more among females than among males. [4]

Depression is recognized as a serious public health concern in developing countries. The Global Burden of Disease study showed that depression will be the single leading cause of Disability Adjusted Life Years by 2020 in the developing world. [5] Depression is the most common psychiatric disorder among the elderly which can manifest as major depression or as minor depression characterized by a collection of mild depressive symptoms. [6] Many studies have indicated severe under-recognition and under-treatment of depression in the elderly, even in developed counties. [7],[8],[9] Prevalence of depression in elderly in India varied from 6% to 50%. [10],[11]

Social support is defined as any information leading the subject to believe that he is cared for, loved and is an esteemed member of a network of mutual obligation. Social support is one of the important factors that plays a major role in maintaining well-being in the aged. Social support is moderator of stressful life events. Lack of social support results in both physical and mental health problems. [12] The social relations integral to an active environment are significant determinants of subjective wellbeing including perceived satisfaction in life in older adults. [13] Social support was a significant predictor of mental health outcome. [14] Elderly who had lost a partner experienced lower self-esteem, resulting in higher emotional loneliness and social loneliness, that is the perception of less support. [15] Social support appears to play a significant role in explaining differences in subjective functioning. People living alone or only with a spouse, particularly the elderly, seem to be at greater risk for disability problems. They should receive particular attention from preventive programs in the community. [16] Social support, self-esteem, and optimism were all positively related to positive health practices; and social support was positively related to self-esteem and optimism. [17] Social support is often used in a broad sense, referring to any process through which social relations might promote health and well-being; it refers to the social resources that persons perceive to be available or that are actually provided to them by non-professionals in the context of both formal support groups and informal helping relations. [18] Definitions of social support fall into two categories. Objective social support indicates what support people have actually received or report to have received. The other is a subjective perception, which captures an individual's beliefs about the available support, and which is more persistently and more powerfully related to health and well being than are objective measures. [19]

Thus this study chose to focus on perceived social support which reflects an individual's feeling that he/she is accepted, loved, and valued by other members of their social network and also focus on actually received social support. It also focuses on whether depression makes a difference in perception of perceived and received social support and whether such an experience should be protective of the individual's mental health.

This study was done with the aim of studying levels of perceived and received social support and determining relationship between social support and depression.

Materials and methods

It was a cross sectional study carried out in the Geriatric Clinic of Psychiatry outpatient services of a tertiary care teaching municipal institute in Mumbai after obtaining Institutional Ethics Committee Approval. A total of 40 patients diagnosed as having depression as per DSM IVTR criteria with age of 60 years or more and having Geriatric Depression Scale (GDS) scores equal to or more than 5 were included in study. The elder having any other present or past psychiatric illness, having uncontrolled medical or surgical disease and not willing to give consent for the study were excluded from the study. A written informed consent was taken from the patients before commencing the study. The scales used were the Geriatric Depression Scale [GDS: SF], Berlin social support scale. Semi-structured proforma was filled to collect demographic details and other relevant information.

This scale was used to measure cognitive and behavioural aspects of social support; to assess quantity, type, and function of social support in general and in stressful circumstances; to investigate dyadic support interaction in stressful situations. We used only perceived and received social support subscales, although the scale has other subscales. In this scale to create objectivity for actually received social support a time frame is specified and specific questions are asked which include "Think about the person who is closest to you, such as your spouse, partner, child, friend, and so on. How did this person react to you during the last week?

This person showed me that he/she loves and accepts me.

This person was there when I needed him/her. Thus it hopes to give a more specific and factual account of the support offered.

On each item the participants indicate their agreement with the statements on a four-point Likert-pe scale.

Possible endorsements are strongly disagree (1),

Somewhat disagree (2),

Somewhat agree (3), and

Strongly agree (4).

Negatively worded items are reversed coded. Scale scores are obtained either by adding up item responses (sum scores) or by generating the scale mean score. The perceived social support subscale, which has 8 items has been shown to have good reliability (Cronbach's alpha = 0.83) and the received social support (11 items) subscale also has good reliability (Cronbach's alpha = .83). The scale also has good validity. [20]

Geriatric depression scale (GDS)

The GDS was first developed in 1982 by Yesavage [21],[22] and others. The GDS has questions which are answered "yes" or "no", instead of a five-category response set. This simplicity enables the scale to be used with ill or moderately cognitively impaired individuals. The scale is commonly used as a routine part of a comprehensive geriatric assessment. One point is assigned to each answer and the cumulative score is rated on a scoring grid. The grid sets a range of 0-9 as "normal", 10-19 as "mildly depressed", and 20-30 as "severely depressed". Although GDS has well-established reliability and validity, evaluated against other diagnostic criteria, responses should be considered along with results from a comprehensive diagnostic work-up. A short version of the GDS containing 15 questions has been developed, and the scale is available in languages other than English. Score 5-9 indicative of mild depression, >9 indicative of moderate to severe depression.

Statistical analysis

Statistical Package for Social Sciences 19 th version (SPSS v.19) was used to analyse the data. Descriptive statistics was used to analyse the demographic variable. Pearson's correlation coefficient(r) was used to study the relationship between social support and depression.

The mean score for the subscale of perceived social support as measured by (Berlin Social Support Scale) was 21.95 (SD = 8.21), the median score obtained by the sample was 23. The mean score for the received social support subscale was 37.40 (SD = 11.26) and the median score was 41. The mean GDS score was 10.25 (3.42) and the median score was 10.50.

There was significant negative correlation between depression scores and total perceived social support subscale score (r = −.413; P < 0.01), suggesting that with the increase in the level of depression there is decrease in the perception of amount of social support. Whereas there was no significant correlation between depression and received social support (r = −.298, n.s).

Discussion

In this study, we found that there was significant negative correlation between depression and perceived social support, meaning that as the level of depression increases perceived social support decreases. [23]

There was no significant correlation between depression and received social support. This phenomenon probably reflects that in depression, the negative cognition impairs the appreciation of the actual received support. It indicates that actually received social support may be good but it is the negative cognition of depression which leads to less perception of the actually received social support. This may lead to persistence of depression. [24] It has been shown that negative interpretation of experience maintains depression and depression can lead to negative interpretation of experience. In depression there is negative view of self, environment and future. [25] More recent research indicates that dysfunctional thinking may indeed have a significant role in depression. Although negative cognition appears to remit along with symptoms of depression, people with a history of depression are more likely to report dysfunctional thinking in the presence of negative mood states than people with no such history. [26] This cognitive component of depression has an effect on perception of social support and social demands. [27] Thus though actually received social support is good, depression alters perception of social support due to negative cognition.

Hence, we conclude that there is obviously a role for perception of social support in elderly and this could be affected in elderly by depression. Adequate treatment of depression both pharmacologically and by counselling/ Cognitive behaviour therapy (CBT) which improves negative cognition would help in the perception of social support for elder who is depressed and aid in recovery.

This study was limited by small sample size and objective assessment from caregiver for offering support is not done.

Additional research is needed to determine whether depression treatments alter the relationship between negative cognition and depression as depression improves. Intervention and reassessment could be the fall out or the next step learning from this study. True assessment of available social support becomes mandatory and it would be erroneous to assume that all elder depressed have poor social support and/or perceive poor social support.

Nandi PS, Banerjee G, Mukherjee SP, Nandi S, Nandi DN. A study of psychiatric morbidity of the elderly population in a rural community in West Bengal. Indian J Psychiatry 1997;39:122-9.http://www.biomedcentral.com/sfx_links.asp?ui=1471-244X-7-57&bibl=B18

van Baarsen B. Theories on coping with loss: The impact of social support and self-esteem on adjustment to emotional and social loneliness following a partner's death in later life. J Gerontol B Psychol Sci Soc Sci 2002;57:S33-42.